Please rate topic.
Average 4.4 of 82 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. Radiographs of the affected wrist are shown in Figure A. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. Following fixation, a "shuck" test is performed and shows persistent instability of the distal radioulnar joint. Incompetence of which of the following anatomic structures is the most likely etiology of this finding?
Radioulnar ligaments of the TFCC
Ulnar collateral ligament
Ulnolunate ligament of the TFCC
Ulnotriquetral ligament of the TFCC
Select Answer to see Preferred Response
The patient has sustained a distal radius fracture and concomitant ulnar styloid fracture. The shuck test is performed after fixation of the distal radius to assess the status of the DRUJ, namely the radioulnar ligaments.
Injuries to the DRUJ often occur with distal radius fractures. The presence of an ulnar styloid fracture may signify injury to the DRUJ. After the distal radius has been fixed, the shuck test is performed. This test is completed with the elbow at 90 degrees of flexion, the forearm in neutral rotation, followed by pronation and supination. The examiner attempts to translate the ulnar in the sagittal plane. Excessive sagittal plane ulnar translation signifies DRUJ injury.
Kim et al. review the effect of ulnar styloid nonunion on functional outcome after distal radius ORIF. Of the 91 patients treated with distal radius ORIF, 22% were found to have a nonunion of the ulnar styloid. There was no difference in wrist functional outcomes, ulnar sided wrist pain, or DRUJ stability.
Sammer et al. reviewed 144 patients undergoing ORIF of the distal radius. The DRUJ was stable in all patients after internal fixation. An ulnar styloid fracture was found in 88 patients. Functional outcome scores were not affected by the presence of an ulnar styloid fracture. Additionally, the size of the fracture, extent of displacement, or healing status did not affect the outcome.
Figure A shows a PA radiograph of the wrist demonstrating a comminuted distal radius fracture with a concomitant ulnar styloid fracture. Illustration A shows an example of the shuck test used to test the DRUJ.
Answer 2: The ulnar collateral ligament is involved with injuries to the thumb.
Answer 3: The shuck maneuver is not utilized to assess stability of the fracture.
Answers 4, 5: The ulnolunate and ulnotriquetral ligament origins are part of the TFCC, but are not the key stabilizers of the DRUJ.
Kim JK, Yun YH, Kim DJ, Yun GU.
Injury. 2011 Apr;42(4):371-5. Epub 2010 Oct 20. PMID: 20961540 (Link to Abstract)
Kim, INJURY 2011
Sammer DM, Shah HM, Shauver MJ, Chung KC.
J Hand Surg Am. 2009 Nov;34(9):1595-602. PMID: 19896004 (Link to Abstract)
Sammer, JHS 2009
Title: Distal Radius Fracture - : What's New?Duration: 15:38 Presenter: Melvin P...
Please rate question.
Average 4.0 of 16 Ratings
A 68-year-old male falls onto his outstretched hand and suffers the injury shown in Figures A and B. He undergoes operative treatment of his fracture, and immediate post-op radiographs are shown in Figure C. Two weeks later he presents with significantly increased pain and deformity. He denies any new trauma, and has followed all post-operative activity restrictions. Current radiographs are shown in Figure D and a clinical photograph of the affected wrist is shown in Figure E. Which of the following is the most likely cause for failure of fixation in this patient?
Failure to support the lunate facet with fragment specific fixation
Use of a non-locking plate
Lack of volar tilt restoration
Lack of radial styloid column plating
Use of only three bicortical screws in the intact radial shaft proximally
The failure of this patient's fixation post-operatively is caused by failure to support the lunate-facet fragment noted on the injury radiographs.
The stability of comminuted fractures of the distal part of the radius with volar fragmentation is determined not only by the reduction of the major fragments but also by the reduction of the small volar lunate fragment. The distal volar lunate fragment is the site of origin of the strong volar radiolunate ligaments which insert onto the lunate, and so displacement of this small piece volarly will allow the lunate and the rest of the carpus to subluxate volarly. The unique anatomy of this fragment may prevent standard fixation devices for distal radial fractures from supporting the entire volar surface effectively, as a standard volar plate cannot capture this small distal piece without risking injury to the flexor tendons. Fragment specific fixation of the volar lunate facet fragment with commercially available small plates, or with a tension-band construct or augmentation with K-wires may be required to reduce and stabilize this fragment.
Harness et al. reported on a cohort of 7 patients with a volar shearing fracture of the distal radius who lost fixation of a volar lunate facet fragment with subsequent carpal displacement after open reduction and internal fixation. Five patients underwent revision surgery with adequate results. The authors concluded that with regards to lunate facet fracture fragments, it is preferable to recognize the complexity of the injury prior to the initial surgical intervention and to plan accordingly to prevent early post-operative failure.
Taylor et al. compared the biomechanical stability of a fixed-angle volar plate versus a fragment specific fixation system in the treatment of an intra-articular, dorsally comminuted distal radius fracture model. They found that both fixed-angle volar plate and fragment-specific fixation systems performed comparably in a simulated early postoperative motion protocol. Fragment-specific fixation had improved stiffness characteristics only with respect to the smaller ulnar-sided fragment.
Figures A and B show a shearing radiocarpal-fracture subluxation with small lunate-facet fracture. Figure C shows an immediate post-operative radiograph. Figure D shows subluxation of the radiocarpal joint caused by failure to support lunate-facet fragment. Figure E shows the clinical appearance of a volarly subluxated wrist.
Answer 2: The use of a non-locking plate in this situation did not directly lead to the failure of fixation, and applying a similar construct with locking fixation would not have prevented volar subluxation of the lunate facet fragment.
Answer 3: Volar tilt was grossly restored post-operatively.
Answer 4: Radial styloid plating would not have prevented volar subluxation of the lunate facet fragment.
Answer 5: Three bicortical screws in the intact radial shaft proximally is adequate fixation.
Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL
J Bone Joint Surg Am. 2004 Sep;86-A(9):1900-8. PMID: 15342751 (Link to Abstract)
Harness, JBJS 2004
Taylor KF, Parks BG, Segalman KA.
J Hand Surg Am. 2006 Mar;31(3):373-81. PMID: 16516730 (Link to Abstract)
Taylor, JHS 2006
Average 4.0 of 33 Ratings
A 17-year-old male falls from a retaining wall onto his left arm. He sustains the injury shown in Figure A. The patient undergoes open reduction and internal fixation of the fracture. Upon discharge from the hospital the medication reconciliation includes an order for daily Vitamin C 500mg supplementation. This medication is given in an effort to decrease the incidence of which of the following?
Upper extremity deep vein thrombosis (DVT)
Acute carpal tunnel syndrome (ACTS)
Complex regional pain syndrome (CRPS)
Lower extremity deep vein thrombosis (DVT)
Surgical site infection (SSI)
The patient has the clinical presentation of a distal radius fracture and Vitamin C administration has been associated with a lower incidence of complex regional pain syndrome (CRPS) in this group of patients.
Vitamin C administration is associated with a lower risk of complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD), after wrist fractures. Vitamin C is thought to reduce lipid peroxidation, scavenge free hydroxyl radicals, protect the capillary endothelium, and inhibit vascular permeability.
Zollinger et al. performed a prospective randomized trial that included 317 adult patients who sustained 328 distal radius fractures and were treated conservatively. They had allocated treatment groups to 200mg, 500mg, or 1500mg vitamin C dosages for 50 days. RSD/CRPS occurrence was lowest in the 1500mg group, however the 500mg dosage for 50 days was recommended at the conclusion of the study. The prevalence of CRPS was 2.4% in the vitamin C group and 10.1% in the placebo group. They found that all of the affected patients were elderly women.
Besse et al. performed a study of 392 patients that underwent foot surgery. They found that the group that received 1 gram daily of Vitamin C following foot surgery had a CRPS incidence of 1.7% compared to a control group that did not receive Vitamin C and had a CRPS incidence of 9.6%.
Figure A is a clinical photo of a distal radius fracture.
Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW
J Bone Joint Surg Am. 2007 Jul;89(7):1424-31. PMID: 17606778 (Link to Abstract)
Zollinger, JBJS 2007
Besse JL, Gadeyne S, Galand-Desmé S, Lerat JL, Moyen B.
Foot Ankle Surg. 2009;15(4):179-82. Epub 2009 Apr 5. PMID: 19840748 (Link to Abstract)
Title: Distal Radius Presenter: R. Kumar Kadiyala, MDColumbia University Orthope...
A 65-year-old female sustains a fall onto her outstretched right hand. The injury is closed and she is neurovascularly intact. There is no median nerve paresthesias. Radiographs are shown in Figures A and B. What is the next best step in management of this patient?
Admit for acute carpal tunnel syndrome monitoring
Admit for acute open reduction/internal fixation
Place into removable soft splint and follow-up in clinic
Place into rigid splint and follow-up in clinic
Place into rigid splint and schedule for outpatient open reduction/internal fixation
Based on the presentation and radiographic findings, the next best step is to place the patient into a rigid splint (ie. sugar tong) and have the patient follow-up in clinic. It is important to closely follow this patient, to assess the stability of the reduced fracture.
Distal radius fractures can be successfully managed when the articular surface has been appropriately reduced and when anatomic relationships have been restored. Indications for closed reduction and rigid immobilization include extra-articular fractures, fractures with less than 5 mm of radial shortening, and fractures with dorsal angulation of less than 5 degrees. Based on the AAOS Clinical Practice Guidelines, this fracture does not meet criteria for operative intervention.
Lichtman et al. discuss the AAOS Clinical Practice Guidelines for managing distal radius fractures. There were only five moderate strength recommendations, which included: 1) surgical fixation for fractures that had a post-reduction radial shortening > 3 mm, dorsal tilt > 10 degrees and intra-articular step off > 2 mm, 2) rigid immobilization for non operative treatment, 3) use of a true lateral to assess the DRUJ, 4) beginning early range of motion of the wrist after stable fixation and 5) use vitamin C to help mitigate intractable pain.
LaFontaine et al. reviewed greater than 100 cases of consecutively treated distal radius fractures. Acute management involved reduction of the fracture and placement in to a plaster cast. Fractures that were more likely to displace were found to have 1) dorsal angulation of > 20 degrees, 2) comminution of the dorsal cortex, 3) intra-articular radiocarpal fractures, 4) an associated ulnar fracture or 5) age greater than 60 years of age. They recommend that patients with 3 or more of these factors should have closer radiologic follow up to guide definitive treatment.
Figures A and B demonstrate a non-displaced, extra-articular distal radius fracture. Because the fracture is appropriately aligned, the patient can be placed into a rigid splint.
Answer 1: This patient does not have evidence of acute median nerve compression.
Answers 2, 5: Because the reduction is within the limits set forth by the AAOS guidelines, operative intervention is not warranted, even in the outpatient setting.
Answer 3: The guidelines indicate that rigid mobilization is warranted when treating distal fractures non-operatively.
Lichtman DM, Bindra RR, Boyer MI, Putnam MD, Ring D, Slutsky DJ, Taras JS, Watters WC 3rd, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Haralson RH 3rd, Boyer KM, Hitchcock K, Raymond L.
J Am Acad Orthop Surg. 2010 Mar;18(3):180-9. PMID: 20190108 (Link to Abstract)
Lichtman, JAAOS 2010
Lafontaine M, Hardy D, Delince P.
Injury. 1989 Jul;20(4):208-10. PMID: 2592094 (Link to Abstract)
Lafontaine, INJURY 1989
Average 3.0 of 17 Ratings
A 63-year-old female sustained a distal radius and associated ulnar styloid fracture 3 months ago after being involved in a motor vehicle collision. Radiographs obtained at the time of injury are shown in Figure A. She underwent open reduction and fixation of the distal radius fracture, and current radiographs are shown in Figure B. At the time of the index operation, there was no distal radioulnar joint instability after plating of the radius. Which of the following is true post-operatively regarding this patient's ulnar styloid fracture?
Worse outcomes on the Mayo wrist score are expected without fixation
Chronic distal radioulnar joint instability can be expected to occur without fixation
Wrist function depends on the level of ulnar styloid fracture and initial displacement
Grip strength and wrist range of motion are improved with fixation
There is no adverse effect on wrist function or stability without fixation
An accompanying ulnar styloid fracture in patients with stable fixation of a distal radial fracture has no apparent adverse effect on wrist function or stability of the distal radioulnar joint.
Kim et al evaluated 138 patients who underwent surgical treatment of an unstable distal radial fracture, without fixation of an associated ulnar styloid fracture if present. Postoperative evaluation included measurement of grip strength and wrist range of motion; calculation of the modified Mayo wrist score; as well as testing for instability of the distal radioulnar joint at a mean of 19 postoperatively. They did not find a significant relationship between wrist functional outcomes and ulnar styloid fracture level or the amount of displacement.
af Ekenstam et al performed prospective and randomized study of two different treatments of extraarticular Colles' fracture with a fractured ulnar styloid. In one group, the ulnar styloid was left alone, and in the other group it was transfixed and/or the triangular ligament was repaired after closed reduction of the fractured radius. They concluded that repair of the ulnar styloid complex in extraarticular fractures of the distal radius is not better than conventional treatment.
Kim JK, Koh YD, Do NH.
J Bone Joint Surg Am. 2010 Jan;92(1):1-6. PMID: 20048089 (Link to Abstract)
Kim, JBJS 2010
af Ekenstam F, Jakobsson OP, Wadin K.
Acta Orthop Scand. 1989 Aug;60(4):393-6. PMID: 2683564 (Link to Abstract)
af, ACTA 1989
Average 4.0 of 22 Ratings
A 67-year-old woman slips on the ice while retrieving her mail and lands on her outstretched left hand. She complains of wrist pain and deformity. On physical exam she has no sensation of the volar thumb, index, and middle fingers. Radiographs are provided in Figure A. Two hours following closed reduction, the deformity is corrected, but the numbness and wrist pain is worsening. Which of the following interventions should be taken?
Evaluation of volar compartment pressures with a needle monitor
Icing and elevation of the arm with follow-up evaluation in 8 hours
Immediate EMG evaluation of the left upper extremity
Closed reduction, carpal tunnel release, and sugar tong splinting
Emergent open reduction internal fixation with carpal tunnel release
The radiograph demonstrates a displaced distal radius fracture along with a scaphoid fracture, and the patient is presenting with neurologic deficits of acute carpal tunnel syndrome. This is a surgical emergency requiring release of the carpal tunnel to prevent permanent dysfunction.
Dyer et al performed a retrospective cohort comparison of patients with distal radius fractures. Fracture translation was the most significant risk factor for development of acute carpal tunnel syndrome. Ipsilateral extremity fracture and multi-extremity trauma were trending, but not statistically significant risk factors.
In a review article, Schnetzler describes the pathogenesis, evaluation, and treatment of acute carpal tunnel syndrome.
Dyer G, Lozano-Calderon S, Gannon C, Baratz M, Ring D
J Hand Surg Am. 2008 Oct;33(8):1309-13. PMID: 18929193 (Link to Abstract)
Dyer, JHS 2008
J Am Acad Orthop Surg. 2008 May;16(5):276-82. PMID: 18460688 (Link to Abstract)
Schnetzler, JAAOS 2008
Average 3.0 of 23 Ratings
A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Three months after the fracture she reports an acute loss of her ability to extend her thumb. What is the most likely etiology of her new loss of function?
Posterior interosseous nerve entrapment
Extensor pollicis longus rupture
Extensor pollicis longus entrapment
Distal radius malunion
According to the referenced article by Jupiter and Fernandez, the most common scenario of extensor pollicis longus rupture after a distal radius fracture is when the fracture is non or minimally displaced. The hypothesis is that the rupture happens at an area of relative hypovascularity and healing callus can aggravate this area, leading to a degenerative tear.
Hove et al reported an incidence of delayed tendon rupture after distal radius fracture of 0.3 percent. In their series of 18 extensor pollicis longus tendon ruptures, 15 were treated with tendon transfers. They reported good results: nearly 100% patient satisfaction, all patients were able to elevate the thumb to the level of the palm, and full independent index finger movements.
Jupiter JB, Fernandez DL.
Instr Course Lect. 2002;51:203-19. PMID: 12064104 (Link to Abstract)
Acta Orthop Scand. 1994 Apr;65(2):199-203. PMID: 8197857 (Link to Abstract)
Hove, ACTA 1994
Average 3.0 of 18 Ratings
A 51-year-old female presents with an acute inability to extend her thumb, four months after she was treated with cast immobilization for a minimally-displaced distal radius fracture. What is the most appropriate treatment at this time?
Occupational therapy for strengthening
Extensor carpi radialis longus transfer to extensor pollicus longus
Extensor pollicis brevis transfer to extensor pollicus longus
Extensor indicis proprius transfer to extensor pollicus longus
Primary repair of extensor pollicus longus
A rare complication of non-displaced or minimally displaced fractures of the distal radius treated with a cast is a delayed rupture of the extensor pollicis longus (EPL) tendon. The EPL is the primary extensor of the interphalangeal joint of the thumb and also assists with metacarpophalangeal extension. Extensor indicis proprius transfer to the EPL is the most widely used and reported treatment for this condition.
Magnussen et al. reviewed results of EIP transfer following ruptures of the EPL, with 19/21 good results. None of the cases had any loss of independent index finger extension although index extensor strength reduced to half of that of the contralateral side.
Hove et al. reported a similar satisfaction rate following treatment of 15 patients. In his series of 4,400 distal radius fractures treated over a 5 year period, the incidence of delayed tendon rupture following distal radius fracture was 0.3 percent.
Magnussen PA, Harvey FJ, Tonkin MA.
J Bone Joint Surg Br. 1990 Sep;72(5):881-3. PMID: 2211775 (Link to Abstract)
Magnussen, BJJ 1990
Average 4.0 of 20 Ratings
Twelve months after open reduction and internal fixation of a comminuted distal radius fracture as seen in Figure A and B, which of the following tendons is at greatest risk of rupture?
Abductor Pollicis Longus
Extensor Pollicis Brevis
Extensor Indicis Proprius
Flexor Pollicis Brevis
Flexor Pollicis Longus
Figure A shows a distal radius fracture treated with a volar locked plate. Historically, distal radius fractures treated with dorsal plates were notorious for extensor tendon irritation with some cited rates as high as 50%.
In the reference by Drobetz et al, they reviewed 50 fractures treated with a volar locked plate. They noted that in 6 (12%) of cases that there was rupture of the flexor pollicis longus (FPL) at a mean of 10 months post operatively.
The second reference by Douthit is a retrospective review of 46 fractures treated with a volar locked plate. Excellent initial and maintenance of reduction was noted in 85% of cases, but FPL rupture occurred in 2 patients. Prominent plates and sharp screws were cited as reasons for tendon rupture.
Drobetz H, Kutscha-Lissberg E.
Int Orthop. 2003;27(1):1-6. Epub 2002 Aug 21. PMID: 12582800 (Link to Abstract)
Drobetz, INTORT 2003
Am J Orthop (Belle Mead NJ). 2005 Mar;34(3):140-7. PMID: 15828519 (Link to Abstract)
Douthit, AJO 2005
Average 3.0 of 32 Ratings
A 54-year-old male falls from a ladder and sustains the fracture shown in Figure A. Which of the following factors has been associated with redisplacement of the fracture after closed manipulation?
Triangular fibrocartilage complex tear
Ipsilateral radial head fracture
Time to reduction
Severity of initial displacement
Several factors have been associated with re-displacement following closed manipulation of a distal radius fracture: the initial displacement of the fracture (the greater the degree of displacement, particularly radial shortening), the age of the patient (older patients with osteopenic bones displace late), and the extent of metaphyseal comminution.
Acceptable radiographic parameters for a healed radius in an active, healthy patient <65 years old include: radial length within 5mm of the contralateral wrist, dorsal tilt <10 degrees, intraarticular step-off of less than 2 mm, and less than 5 degree loss of radial inclination.
Figure A shows a lateral view of a distal radius fracture.
Ilyas and Jupiter review the classification, treatment, and operative indications for distal radius fractures in the referenced review article.
Ilyas AM, Jupiter JB.
Orthop Clin North Am. 2007 Apr;38(2):167-73, v. PMID: 17560399 (Link to Abstract)
Average 3.0 of 24 Ratings
A 46-year-old woman sustains an extra-articular fracture of the distal radius and undergoes open reduction and internal fixation with a volar plate and screw construct. During postoperative recovery from this injury, what benefit does formal physical therapy have as compared to a patient-guided home exercise program?
Greater grip strength at 6 months
Less wrist pain at 1 year
Better hand dexterity at 1 year
No difference in functional outcomes
Quicker return to work
There are no significant benefits demonstrated with formal physical therapy following distal radius fracture ORIF compared to a patient-guided home exercise program.
The reference by Wakefield and McQueen is a randomized controlled trial of 96 patients, comparing formal hand physiotherapy to a home exercise regimen. There was no difference in grip strength, pronation/supination, radial/ulnar deviation, or hand function. The authors concluded that there were no significant benefits to formal physiotherapy.
The study by Souer et al is a level I study evaluating formal therapy and patient-guided exercise program for patients who underwent ORIF of a distal radius fracture with a volar plate and screw construct. This study showed a significant decrease in wrist ROM and grip strength with formal therapy. There were no differences in arm-specific disability (DASH score) at any time point.
Wakefield AE, McQueen MM.
J Bone Joint Surg Br. 2000 Sep;82(7):972-6. PMID: 11041584 (Link to Abstract)
Wakefield, BJJ 2000
Souer JS, Buijze G, Ring D
J Bone Joint Surg Am. 2011 Oct;93(19):1761-6. PMID: 22005860 (Link to Abstract)
Souer, JBJS 2011
Average 3.0 of 19 Ratings
Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios?
Non-displaced distal radius fracture
Non-displaced Rolando fracture
Second metacarpal base fracture
Non-displaced radial styloid fracture
Rupture of the extensor pollicis longus (EPL) tendon after non operative treatment for a distal radius fracture occurs with a 0.3-5% incidence. The causes of EPL rupture include mechanical irritation, attrition, and vascular impairment leading to delayed rupture. Synovitis of the extensor carpi radialis due to repetitive use may invade the EPL tendon and lead to rupture. Recommended treatment in the pre-rupture setting includes a third dorsal compartment release with or without an extensor retinacular patch graft. Palmaris longus graft or a transfer from the extensor indicis proprius to the EPL tendon are reasonable treatment options. Results of all treatments seem to be clinically satisfactory.
The referenced article by Gelb is a review of the etiology and treatment of this injury. He reviews the above discussion and findings.
Hand Clin. 1995 Aug;11(3):411-22. PMID: 7559819 (Link to Abstract)
Gelb, HANDC 1995
Average 3.0 of 22 Ratings
A 25-year-old female falls from her horse and injures her left wrist. There are no open wounds and the hand is neurovascularly intact. Radiographs are provided in Figures A-C. Which of the following will best achieve anatomic reduction, restore function, and prevent future degenerative changes of the wrist?
Long arm cast above the elbow for 6 weeks
Long arm cast for 3 weeks followed by a short arm cast for 3 additional weeks
Closed reduction and external fixation
Closed reduction and percutaneous pinning
Open reduction and internal fixation
The radiographs demonstrate an intra-articular distal radius fracture with dorsal angulation. Most importantly, there is a large dorsal articular fragment. Open reduction of this fragment is best acheived through an open approach. The choice of dorsal vs. volar approach is debatable, but most importantly the articular surface, radial height, and volar tilt must be reduced anatomically.
Yu et al reviewed 104 distal radius fractures treated with either dorsal or volar plating. There was no difference in the rate of tendon irritation or rupture between the groups. Volar plating was associated with significantly more neuropathic pain complications.
Illustrations A and B demonstrate the open reduction and internal fixation of this fracture with a dorsal plate.
Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day CS
J Hand Surg Am. 2011 Jul;36(7):1135-41. PMID: 21712136 (Link to Abstract)
Yu, JHS 2011
HPI - History of fall 2 months ago and was treated by in another setup with a cast for 6 weeks. The patient has had 2 weeks of physical therapoy. Currently, he has moderate wrist pain with functional range of motion
How would you treat this patient?
Average 3.0 of 30 Ratings
A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. Adequate maintenance of reduction by non-operative treatment is unsuccesful. Which plating option provides the most appropriate treatment of this fracture?
limited-contact dynamic compression
Egol et. al. studied locked and conventional plates. They concluded that locked plates may be increasingly indicated for indirect fracture reduction, diaphyseal/metaphyseal fractures in osteoporotic bone, bridging severely comminuted fractures, and the plating of fractures where anatomical constraints prevent plating on the tension side of the bone. Conventional plates remain the fixation method of choice for periarticular fractures that demand perfect anatomical reduction, and certain types of non-unions that require increased stability for union.
Sommer C, Babst R, Müller M, Hanson B
J Orthop Trauma. 2004 Sep;18(8):571-7. PMID: 15475856 (Link to Abstract)
Sommer, JOT 2004
Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ.
J Orthop Trauma. 2004 Sep;18(8):488-93. PMID: 15475843 (Link to Abstract)
Egol, JOT 2004
A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. Two-point discrimination is now >10mm in these fingers. Radiographs show a well-fixed fracture in good alignment. What is the most appropriate treatment at this time?
Removal of hardware
Immediate carpal tunnel release
Carpal tunnel release if no resolution at 6-12 weeks
Trial of night splinting
This patient had mild median parasthesias preoperatively that have significantly worsened postoperatively. Immediate carpal tunnel release is the most appropriate next step in treatment.
Mack et al reported on ten cases of acute carpal tunnel syndrome (ACTS) and six cases of nerve contusion in patients with acute median neuropathy associated with blunt wrist trauma. The patients with ACTS initially had normal sensation and subsequently developed objective sensory loss (2-point discrimination greater than 15 mm) in the median nerve distribution associated with severe wrist pain. In contrast, patients with nerve contusion injuries had immediate sensory loss and symptoms were nonprogressive. Four of five patients with ACTS who underwent carpal tunnel release within 40 hours of the onset of numbness had normal 2-point discrimination within 96 hours. Neuropathy, secondary to nerve contusion without coexisting ACTS, may be treated initially by observation.
Ford et al reported of five cases of ACTS. Four with delayed treatment had poor outcomes while the one patient with early CTR had full recovery. All patients with ACTS had increasing and severe pain in the wrist with parasthesia and impaired sensation in the median distribuation. These symptoms initially weren’t present after wrist trauma, but developed rapidly in the next few hours.
Ford DJ, Ali MS.
J Bone Joint Surg Br. 1986 Nov;68(5):758-9. PMID: 3782239 (Link to Abstract)
Ford, BJJ 1986
Mack GR, McPherson SA, Lutz RB.
Clin Orthop Relat Res. 1994 Mar;(300):141-6. PMID: 8131326 (Link to Abstract)
Mack, CORR 1994
Average 4.0 of 17 Ratings
A 32-year-old ballet dancer sustains a distal radius fracture, and is subsequently closed reduced and casted. She presents 11 months later with the radiograph seen in Figure A, complaining of significant wrist pain. What is the appropriate surgical treatment at this time?
Distal radius corrective osteotomy
Total wrist arthrodesis
Proximal row carpectomy
Scaphoid excision and four corner fusion
The lateral wrist radiograph in Figure A shows significant dorsal angulation of the distal radius with a maintained joint space. The most appropriate surgical treatment for this patient would include corrective osteotomy of the distal radius, as there is no evidence of degenerative changes. If degenerative changes would be present, a salvage procedure such as total wrist arthrodesis would become an option.
The referenced article by Fernandez recommended distal radius corrective osteotomy with bone grafting and internal fixation for the following indications: 1) manually active patients who had a symptomatic extra-articular malunion of the distal end of the radius causing angulation of more than 25 to 30 degrees in either the frontal or sagittal plane without significant degenerative changes in the wrist joint (such as narrowing of the joint space, intra-articular incongruency, subchondral sclerosis, and osteophytic reaction) and in whom it was thought that the result of either a Darrach procedure or shortening osteotomy of the ulna would be uncertain because the deformity of the radius would not be corrected, and 2) patients who wished to have the deformity corrected even though they had adequate function of the wrist.
J Bone Joint Surg Am. 1982 Oct;64(8):1164-78. PMID: 6752150 (Link to Abstract)
Fernandez, JBJS 1982
HPI - h/o fall 2 mths then treated with a cast without any manipulation at another centre.cast was on for 1 mth.
Average 4.0 of 21 Ratings
Title: Current Solutions in Orthopedic Trauma - Distal Radus Fractures - 2016 A...
Title: Orthobullets Case 2 Author: Duration: 4:13
Title: Faculty Panel Authors: Duration: 14:47
Title: Distal Radius Fracture Author: Brandon Earp, MD Duration: 19:56
Distal Radius Fixation with Volar Locking Plate by a Minimally Invasive Approach...
In this patient there is extensor tendon rupture due to K wire irritation follow...
HPI - History of fall down on left wrist one month ago.
The patient is neurovascular intact. The fracture was an open fracture (type 1) with a small wound on the volar aspect of the distal ulna. At the time of the injury, this was treated operatively with irrigation and debridement and placement of an ex-fix spanning the fractures.
Currently, the wound has healed. There is no sign of infection.
CRP and ESR are normal. XRays are shown.
How would you manage this patient at this time?
HPI - A 65 year old man present to ER after a fall from 8 meters, injuring his wrist.
Would you order a CT scan to further evaluate the fracture?
HPI - Fall on the ground about 1 month ago leading to fracture of left distal radius. He went to a hospital then reduction under anesthesia was done and cast applied for 3 weeks. He now returns complaining of wrist deformity.
Would you obtain any additional imaging to determine treatment?
HPI - history of domestic fall due to slip in bathroom
How would you have treated this original fracture?
HPI - 71 year old male who fell on out-stretched hand. Active, otherwise healthy. Patient lives alone and is widowed.
HPI - RTA
How would you treat this fx after closed reduction (see postprocedure P1 below)?
HPI - Distal radius-ulna open fracture 16 weeks ago treated initially with ex-fi. Then due to an infection , antibiotics were administered and pins were introduced for an extra fracture stability. The ex -fi was remover after 10 weeks from the accident
How would you treat this synostosis after treatment of a distal radius fx with an ex-fix?
HPI - pain inabilty to move the rt wrist after a fall
How would you treat this fracture?
HPI - Patient had injury of his distal radius 7 months ago. Patient was treated by closed reduction and external fixator application. The fixator removed at 6 weeks. The deformity progressed after that.
Is this a malunion or a nonunion?
HPI - Sustained open fracture of distal radius and ulna after he was injured by a heavy gate of a truck.
Underwent Irrigation/debridement and application of external fixator - distal radius and orif of distal ulna.
Patient is 2 weeks post op.
How would you have treated this open fracture on initial presentation?
HPI - Had sustained the injury on 1-2 june. Since it was in a distant village didnt seek medical advice. Presented to trauma outpatient center on 6 june.
How would you manage this fracture?
HPI - Fell at home, multifragmentary and bifocal fracture of distal radius with complete articular involvement, multifragmentary fracture of distal ulna.
What would be the choice treatment?
HPI - history of fall from bike on 01/14/2015 . primary treatment given by surgeon locally who reduced the wrist and applied plaster slab.
How would you treat this injury?
HPI - Had a fall from height 6hrs ago.
What would be the plan of management.
HPI - Sustained a wrist fracture after a MVA. person was in the vehicle.injury to the wrist was taken to another hospital where under sedation they reduced the fracture and put her in a slab.
seen at our hospital 1 week following the injury
How would you treat this fracture at this time (one week after injury)?
HPI - severe pain in the wrist
inability to move the wrist
what is the best treatment option ?
HPI - Patient suffered from closed distal 1/4 both bones fracture 6 weeks ago treated by closed reduction and percutaneous pinning by k wires
First presentation in our clinic with obvious angulation and limited supination 6 weeks after trauma with subluxation of distal radioulnar joint
HPI - Fall on outstretched arm at home.
HPI - Trauma since 5 days with good local skin conditions
How would you treat the right sided distal radius fracture
HPI - Male pt 48 y old , manual worker (high demand), Rt handed, fell over his Rt hand
HPI - road traffic accident 1 year ago and there is fracture right distal radius.intially treated by bone settler. Now complaint of pain and deformity and difficulty in performing daily activities.
what is the best treatment?
HPI - 3 mt fall over outstretched right hand, also presents not displaced isquial and pubic bone fracture
HPI - RHD male with Left distal radius ORIF hardware failure 6wks postop after fall on ice. Interesting that he doesn't have much pain and ROM is suprisingly good at 55 flex/ext and 20 of ulnar/radial deviation.
what is the next step with revision?
HPI - RTA, patient as the driver. Inittially managed at a regional hospital, then transferred to our hospital. Diagnosed with left acetabular post. wall fracture (already fixed), left 2, 3, 4th MTT diaphyseal fractures, right pilon fracture C3, right distal radius fracture C3. All fractures closed, no other injury diagnosed.
How would you manage the distal radius fracture?
HPI - This is a 19 year old manual laborer whose nondominant left hand was pulled violently into a machine at work. He is neurovascularly intact. It is difficult to examine his carpus for a scapholunate injury given his pain, but on XR his films are suspicious for a widened scapholunate injury. He presented for treatment 2 days after injury.
How would you treat this patient operatively?
HPI - Fell down playing Padel 3 days ago. Non dominant hand, independet for daily life activities
How should this patient be treated?
HPI - Patient sustained a communited distal radius fracture 3 months prior to presentation. The patient underwent closed reduction and external fixation. After removal of external fixator at 6 weeks deformity progressively increased.At present patient has NO PAIN but pronation and supination are limited and there is decrease in dorsiflexion.
How would you treat this patient now?
HPI - 33 y/o male s/p fall and distal radius fracture. Treated ~3 weeks ago at outside hospital with volar plate/screws. Has been using hand for work as a mechanic; c/o continued wrist pain.
How would you treat this pathology?
HPI - History of fall 3 week back
Closed reduction done
What should be further course of treatment
HPI - road traffic accident
What should be the next step in treatment for this patient with an articular step-off on the postoperative films?
HPI - 17.02.2013
30 years old man. he is crane operator.his dominant hand was injuried.I attached closed reduction films and ct and I am sorry for bad quality of films.What is the best treatment? has been created.
HPI - h/o fall 1 month ago.slipped on snow.patient has very minimal pain at present.dorsiflexion and platar flexion terminal restricted.
orif with bone grafting or allow healing
HPI - History of RTA,with extensive soft tissue injury on extensor compartment of forearm with loss of extensor tendons
What is the best option
HPI - case of radius farcture seen a week after surgery for a second opinion
is there volar instability alon with dorsal tilt and need a redo
HPI - pain inabilty to move rt wrist after fall
open reduction internal fixation or external fixators
HPI - fall while playing cricket.
open reduction internal fixation or k wiring with external fixators.additinal bone graft vs calcium po4
HPI - h/o fall from height pain and inability to move lt wrist
orif or external fixator with k wires
HPI - Patient seen at outside hospital, told to followup at University for fixation
What would you do for this injury?
HPI - s/p rollover accident with her arm out of the window
What would be your initial treatment of choice for the forearm/wrist injury?
HPI - 45yo RHD M s/p injury to R forarm while working on garage door
What should initial treatment for this injury be?